Student Health Insurance Confirmation Form - St. George's University

Student Health Insurance Confirmation Form
January 1, 2006 – July 31, 2006
All St. George's University students must maintain adequate health insurance and must confirm their coverage
annually on this form. You must complete and return this form to the Student Health Insurance Office. No student
may register for classes until this form has been submitted and the health option documented. Students may
choose to enroll in the University sponsored program offered by Student Resources (underwritten by MEGA Life
and Health Insurance Company) or in any other program that provides them with adequate health insurance
coverage. All relevant information is available in Student Health Insurance Section of www.sgu.edu. My SGU..
See IMPORTANT NOTES ABOUT YOUR CHOICES on the reverse side of this form.
Last Name: First Name: SS# or ID#:
Cell Phone: Birth Date: Email (ID@SGU.edu)
1. I request coverage (new or continued) under the University sponsored MEGA policy and would like the
University to bill the premium to my student account. I have funding from student loans; the Office of
Student Finances may deduct the cost of my health insurance policy from my Stafford and/or private
loans. (This policy includes air assistance) (pf. 1A or 1B)
Policy 1 Policy 2
1a. I also request coverage (new or continued) under the University sponsored MEGA policy for the
dependents listed in the Dependents Summary. I understand the premium rates for dependents that are
listed in the on-line brochure are higher than the rates for students and cannot be paid with student loans.
Dependents Summary: (documentation for questions 1a and/or 1b) (pf. 1B-E or 2B-E)
Spouse: Birth Date: SS#:
Child: Birth Date: SS#:
Child: Birth Date: SS#:
2. a. I have adequate health insurance coverage to pay for expected and unexpected medical expenses
that may occur during my enrollment. I fully understand that I am legally responsible for any medical
expenses incurred during my enrollment and that the University will not be responsible for any medical
expenses. (pf. 3) Clinical Science students must include a paid in full policy marked “Notice of
Termination Assigned to St. George’s University” along with this form.
b. I have air assistance through my insurance policy listed below.
Name of Health Insurance Carrier:
Policy #:
Telephone Number of Carrier:
Address; _______________________________ City, State, Zip, country: ________________________
3. Enroll me and/or Enroll the dependents listed above, in the stand-alone air evacuation policy with
Student Resource and Assist America. I certify my health insurance policy will pay benefits to whatever
facility the air assistance company determines will provide treatment and care. I further understand that I
may not be allowed into a country or facility without immediate proof of full insurance coverage. (pf. 4)
and/or (pf 5 or 1E, 2E)
Student Signature:
Date:
Return to: Student Health Insurance Office Telephone: 1(800)899-6337 Ext. 232
1 East Main Street, Suite 233 Fax: 1(631)666-9162
Bay Shore, NY 11706 Email: medins@sgu.edu

Important Notes About Your Choices
1. Policy coverage is from August 1, 2005 to July 31, 2006, or January 1, 2006 to July 31, 2006 for
those entering School in January 2006. The one-year pre-existing condition exclusion (any illness
treated in the year prior to the first date of enrollment in the policy) should be taken into
consideration if you are choosing the MEGA program for the first time unless you can provide
HIPPA, proof of previous and continuous coverage.
• The annual insurance premium is NON-REFUNDABLE unless you are not enrolled the first 31 days
of the policy year. Students who are not enrolled for the first 31 days will have the premium
refunded and the policy cancelled without any further notice.
• If you choose to enroll or continue your enrollment in the MEGA program, you will receive a bill for
the annual premium on your SGU student accounts statement. January entering students will be
billed for the seven month policy, (January-July), on their first term’s statement and will be required
to reconfirm health insurance coverage the following August.
• If your loan applications are complete and approved at the time payment is due you may, as with
other University charges, defer payment until your loans are disbursed.
• Eligible students may borrow the amount for health insurance from student loan programs by
contacting their financial aid counselor and completing the necessary paperwork. However, you
may not borrow or use your financial aid to pay for dependent policies. You will be asked to send a
personal check to pay for dependent policies.
. By checking box 2a you are certifying that you will maintain adequate health insurance throughout
the year 8/1/05 to 7/31/06. Please consider that your current policy may not continue
coverage after age 25. If you will turn the age of 25 during this year and your existing
coverage will expire, you should enroll in the MEGA or some other program. You can only
join the MEGA program in August or January. If you are studying on the islands of Grenada or
St. Vincent you will need air evacuation coverage and must also check 2b or 3.
• By checking 2b, you are certifying that your health insurance carrier will provide air evacuation
benefits as well as health insurance benefits for your treatment and care. It is your responsibility
to provide your family and the Director of University Health Services, Attn: Dr. V. Chellapilla
in Grenada, the information about your health and air evacuation policy to use in an
emergency situation. Please send a copy to our office to keep on file.
• By checking 3, you are requesting the stand alone air assistance policy and also certifying that
your health insurance will pay benefits at whatever facility you are taken to in an emergency. The
$40.00 ($74.00 per family) charge for the stand-alone policy will be billed to your student account.
Obviously it could put you in great harm should you arrive in a country and/or facility that would not
accept you as a patient because they lacked proof of insurance. It is your responsibility to
provide your family, the Director of University Health Services, ATTN: Dr. V. Chellapilla in
Grenada, and our office with the information about your health insurance benefits should it
become necessary to call the air ambulance on your behalf.
2. Clinical Science Medical Students who do not take the Mega policy (box 2), must include a copy of the
paid in full policy marked “notice of Termination Assigned to St. George’s University along with this
form. We will view you failure to do so by July 25th, 2005 as your notice to be enrolled instead in the
Mega Policy Option 1. The cost of the policy will be applied to your student account. Please give the
following address to your insurance company for notification of policy termination.
Student Health Insurance Office, One East Main Street, Suite 233, Bay Shore, NY 11706.
See Dean Weitzman’s memo to clinical students regarding health insurance.